Pancreatic Non-Hodgkin Lymphoma Presenting as Pancreatitis and Duodenal Polyps in a Pediatric Patient.

Abstract

To the Editor: Primary gastrointestinal (GI) Burkitt lymphoma (BL) is rare and usually presents in the intestine. There are only 3 case reports of BL involving the pancreas (1–3). A 12-year-old obese boy presented with 3 days of abdominal pain, nausea, vomiting, and scleral icterus. Family also reported 3 weeks of fever and pain in his distal thighs after a recent fall. There was abdominal tenderness and a 2-cm, palpable, nontender cervical lymph node on examination. Transaminases (GGT 875 U/L, ALT 431U/L), bilirubin (2.9 mg/dL) and lipase (>4× ULN) were elevated. Antibody profile was negative for past or current Epstein-Barr infection. Ultrasound showed distended gallbladder with sludge but no calculus (Fig. 1A), distended common bile duct (CBD; Fig. 1B), and findings suggestive of acute pancreatitis (Fig. 1C). ERCP was arranged to evaluate for CBD obstruction. However, a nonobstructing, large, ulcerated gastric mass (Fig. 1D) and 2 duodenal polyps (1 seen in Fig. 1E) were found on endoscopy. Excisional biopsy showing small blue cell tumor and subsequent flow cytometry confirmed an aggressive form of BL. Endoscopic ultrasound did not identify CBD or pancreatic duct abnormality. CT scan showed a mass in the pancreatic body.FIGURE 1: Abdominal ultrasound and endoscopic images. (A) Ultrasound image with arrow pointing to distended gallbladder with sludge but no calculus. (B) Ultrasound image of distended common bile duct indicated by arrow and measured at 7.9 mm. (C) Ultrasound image with pancreas margins indicated by dashed line. There is marked heterogeneity and thickening of pancreas with a hypoechoic area indicated by the arrow suggestive of acute pancreatitis. (D) Endoscopic image of ulcerated mass on the lesser curvature of the stomach. (E) Endoscopic image of 1 of 2 large duodenal polyps.This case illustrates a rare presentation of BL and is the first to report BL forming a duodenal polyp. As no anatomic obstruction was visualized, CBD dilation may have been related to lymphoma in the pancreatic head or ampulla. This highlights the importance of keeping a broad differential and paying attention to small discrepancies in an uncommon presentation of common diseases.